Part 7 – Protected Committees for Quality Improvement Activities

Overview

Part 7 application process

Part 7 committee information and confidentiality

Part 7 committee membership information

Part 7 committee membership responsibilities

Part 7 committees - Terms of Reference

Documents

Overview

Part 7 of the South Australian Health Care Act 2008 (the Act) provides for the declaration of activities to be authorised quality improvement activities or authorised research activities and for persons or groups of persons (committees) to be authorised entities for the purpose of carrying out such activities.

The role of a Part 7 committee is to assess or evaluate health services with the aim of improving the quality of services, make recommendations about the provision of services and implement and monitor any recommendations.   

As detailed in Part 7 s63 (2) of the Act this involves:

‘Undertaking or making assessments, evaluations or recommendations with respect to the practices, procedures, systems, structures or processes of a health service:

  1. where the purpose of any such activity is wholly or predominantly to improve the quality and safety of health services; and
  2. where the public disclosure of, or public access to, information is restricted in order to achieve the best possible outcomes associated with the improvement of health services.’

Under the Act, committees must be established in accordance with the rules of the governing body of the prescribed health sector body and members must hold relevant qualifications.

Any information that could be used to identify the patient or service provider cannot be disclosed to anyone who is not an authorised Part 7 committee member. This includes protection from disclosure in any legal proceedings.

Only Part 7 committee members can attend Part 7 committee meetings. Chief Executives, Board members or other hospital staff are not permitted to attend Part 7 Committee meetings on an ad-hoc basis. 

Application process

Committees must seek authorisation in accordance with Section 64 of the Act by submitting the following application documents to SA Health’s Safety and Quality Unit:

  • SA Health’s Part 7 committee application form. All sections of the form must be completed.
  • The committee’s terms of reference. This document must meet the requirements of the Act.
  • Any other associated documents, if applicable.

For current Part 7 committees, the application must be submitted three months prior to the expiry of the existing declaration.

The Safety and Quality Unit will assess the application against the requirements of the Act.

The applicant must demonstrate that they are conducting either quality improvement or research activities and provide information that defines the role and responsibilities of the committee in relation to these activities.

If an authorised committee has a sub-committee that views protected information, the sub- committee must be separately authorised to allow them to view the Part 7 committee information.

The Safety and Quality Unit will liaise with the applicant to ensure that the application meets the requirements of the Act. When the application meets these requirements, the Safety and Quality Unit will submit a re-authorisation request to the Minister’s Office.

If the application is accepted by the Minister for Health and Wellbeing, the Part 7 committee will be authorised by publishing a Notice in the Government Gazette.

Following publication in the Government Gazette, the Safety and Quality Unit will email the applicant with a copy of the Gazette and the applicant’s documents that were used for the gazetting.

An authorisation made under the Act has effect for three years from the date the notice appears in the Gazette, unless the Minister places a notice in the Gazette revoking the authorisation at an earlier date.

If an authorised Part 7 committee requires re-authorisation for a further three years they will need to submit their application documents three months prior to the expiry of the declaration. The current application form can be obtained from this webpage.

If an authorised Part 7 committee is considering any changes to the committee’s functions they will need to submit these changes to SA Health’s Safety and Quality Unit for review.

It is important that the authorised Part 7 committee continues to operate in accordance with the functions as stated in the original gazetting application until the Safety and Quality Unit has provided advice on any proposed changes.

The Safety and Quality Unit will review the proposed changes and determine if there is a requirement to re-gazette the Committee.

Part 7 Committee information and confidentiality

Protecting the confidentiality of information generated through Part 7 committees encourages open communication in assessing the management, processes and outcomes of the provision of health services.

As detailed in Part 7 s63 (2) of the Act ‘the public disclosure of, or public access to, information is restricted in order to achieve the best possible outcomes associated with the improvement of health services’.

Only Part 7 committee members can have access to confidential information. Chief executives, board members or other staff cannot receive protected information unless they are an authorised person as a member of the committee.

As detailed in Part 7 s63 (1) of the Act, confidential information means:

‘(a) information relating to a health service in which the identity of a patient or person providing the service is revealed; (b) other information declared by the regulations to be confidential information for the purposes of this Part;’

Information protected by Part 7 committee authorisation cannot be legally released to anyone who is not a committee member. This includes the release of information to any court proceeding.  

Information relating to Part 7 committee activities must be de-identified prior to circulation outside of the committee or included in any reports.

The Health Practitioner Regulation National Law (South Australia) Act 2010  states that members of quality assurance committees cannot disclose information because Part 7 of the Health Care Act prohibits such disclosure. Refer to in Schedule 2, Part 8, Division 2 of this legislation for further details.

If any provision in any Act or law is inconsistent with the requirements of Part 7of the Act, the requirements of Part 7 must be followed.

Part 7 Committee membership information

Part 7 committee attendees must be the nominated representative, or a standing appointment. There is no provision for proxies should members be unable to attend the meeting, unless the person attending is formally acting in the member's position.

Experts who are invited to attend a Part 7 committee meeting must be advised of their responsibilities under Part 7 of the Act and acknowledge their obligations by signing the ‘Agreement form for experts invited to a Part 7 committees’.

This form is included in SA Health’s Information for members of committees authorised under part 7, section 64 of the Health Care Act 2008 (SA) (PDF 166KB). 

An ex-officio, such as a person who is executive support, must be included in the membership as they view protected information. Their role must be defined by their position, as the term ‘ex-officio’ is not a form of membership in itself. The membership definition can state that they are a non-voting member and do not contribute to the quorum.

Consumer representatives cannot be a member of an authorised committee, as under the legislation they are considered as ‘members of the public’. However a staff member who is responsible for consumer liaison etc. can be a member of a Part 7 committee.

Part 7 committee membership responsibilities

The Chair of a Part 7 committee must ensure that:

  • The committee only operates within its authorised terms of reference
  • All members are aware of their responsibilities under Part 7 of the Act
  • Systems are in place for the appropriate storage of confidential information
  • The necessary processes are undertaken to obtain reauthorisation (if required) prior to the lapse of authorisation.

Members of Part 7 committees must ensure that:

Part 7 Committees - Terms of Reference

The following information must be included in the committee’s terms of reference:

  • Background section
  • The committee’s function
  • The committee’s membership
  • Statement that proxies are not permitted, unless someone is formally acting in a member’s position
  • The process for keeping information confidential
  • Quorum statement
  • Version control 
  • The date the committee approved the terms of reference

If an authorised committee is considering any changes to their authorised terms of reference, the proposed changes must be submitted to the Safety and Quality Unit for review.

The authorised Part 7 committee must continue to operate in accordance with the authorised terms of reference until the Safety and Quality Unit has provided advice on any proposed changes.

Documents

Please refer to the following for further information:

This is the relevant legislation regarding Part 7 committee activities. 

If any provision in any other Act, law or regulation is inconsistent with the requirements of Part 7 of the Act, the requirements of Part 7 must be followed.

In addition to providing further information, this document contains the agreement forms for Part 7 committee members and invited experts.    

This SA Health document has been prepared to ensure a uniform approach to the establishment and operation of protected committees across SA Health. The Directive provides governance outlining the responsibilities of committee members and health services.

Contact

Safety and Quality Unit

Email: HealthSafetyandQuality@sa.gov.au

Telephone: (08) 8226 6304